Influenza and End-Stage Renal Disease: A Fatal Combination.

Influenza epidemics are a major health care problem in the United States causing significant morbidity and mortality. Influenza can occur in all individuals, but immunocompromized hosts and those with chronic diseases such as end-stage renal disease are more susceptible to its fatal complications. Influenza though is largely preventable with the availability of highly efficacious vaccines. Despite the wide array of vaccine types available, the vaccination rates remain dismal, thereby leading to high incidence of the disease. In this report, we discuss a case of an unvaccinated patient with end-stage renal disease who contracted the influenza virus with fatal consequences. This report discusses multiple factors that allowed for a highly preventable disease to cause this negative outcome and provides suggestions to prevent such outcomes in the future.

Asymptomatic Cecal Perforation in a Renal Transplant Recipient After Sodium Polystyrene Sulfonate Administration.

Sodium polystyrene sulfonate (SPS) is a medication commonly used for the treatment of hyperkalemia. There have been many cases of colonic necrosis and perforation associated with administration of SPS. There are very few such cases reported in renal transplant patients. We present a case of renal transplant recipient who developed cecal perforation after a single oral dose of SPS. She had no signs or symptoms suggestive of intestinal perforation and was incidentally diagnosed with it on abdominal imaging performed to find cause of acute blood loss anemia. This case underlines the importance of recognizing this severe and potentially life-threatening complication associated with SPS. The clinicians should also consider renal/solid organ transplant and immunosuppression as potential risk factors.

Ileal Neobladder With Mucous Plugs as a Cause of Obstructive Acute Kidney Injury Requiring Emergent Hemodialysis.

Ileal neobladder is the preferred technique in the management of urinary diversion postradical cystectomy for bladder malignancy. The common complications associated with this procedure are atrophied kidney, chronic pyelonephritis, decreased renal function, ureteroileal or urethral anastomotic site stricture, urinary tract stones, incontinence, and hyperchloremic metabolic acidosis. Mucous plugs are also seen in 2%-3% patients. We present a rare presentation of a patient who required hemodialysis for severe hyperkalemia and acute kidney injury caused by mucous plugging of ileal neobladder.

An Unrecognized Rash Progressing to Lyme Carditis: Important Features and Recommendations Regarding Lyme Disease.

We present a case report of 46-year-old man with no medical history, who complained of extreme fatigue, near-syncope, and palpitations. He initially presented in complete heart block. A transvenous pacemaker was placed in the emergency department, and he was started empirically on Ceftriaxone for Lyme disease. He was admitted and over the course of the next few days, his rhythm regressed to Mobitz type I first-degree atrioventricular block and then to normal sinus rhythm. This case report highlights some important features regarding Lyme carditis, a rare presentation of early disseminated Lyme disease (seen in a few weeks to months after the initial tick bite). In 25%-30% of patients, the characteristic targetoid rash may not be seen, a likely culprit of the disease not being detected early and progressing to disseminated disease. The most common cardiac complaint of Lyme disease is palpitations, occurring in 6.6% of patients, which may not accurately reflect progression into disseminated Lyme disease because it is a nonspecific finding. Conduction abnormality, occurring in 1.8% of patients, is a more specific finding of Borrelia invading cardiac tissue. Finally, this case report highlights a recommendation that patients with confirmed Lyme disease or those presenting with cardiac abnormalities or symptoms who have an atypical profile for a cardiac event should be screened with a 12-lead electrocardiogram, Lyme serology, and be considered for antibiotic therapy with the possibility of temporary pacing.

Diagnosis and Treatment of Cerebral Salt Wasting Syndrome With Cryptococcal Meningitis in HIV Patient.

Hyponatremia is one of the most common electrolyte imbalances in HIV patients. The differential diagnosis may include hypovolemic hyponatremia, syndrome of inappropriate antidiuretic hormone secretion (SIADH), and adrenal insufficiency. Here, we describe a case of hyponatremia secondary to cerebral salt wasting syndrome (CSWS) in an HIV patient with cryptococcal meningitis. A 52-year-old man with a history of diabetes and HIV was admitted for headache and found to have cryptococcal meningitis. He was also found to have asymptomatic hyponatremia. He had signs of hypovolemia, such as orthostatic hypotension, dry mucosa, decreased skin turgor, hemoconcentration, contraction alkalosis, and high BUN/Cr ratio. The laboratory findings revealed sodium of 125 mmol/L, potassium of 5.5 mmol/L, urine osmolality of 522 mOsm/kg, urine sodium of 162 mmol/L, and urine chloride of 162 mmol/L. We started normal saline for hypovolemia, each 1 L prior and after amphotericin therapy. However, hypovolemia did not improve significantly despite IV fluid. Cosyntropin stimulation test was negative, and renin level was 0.25 ng·mL·h, with the aldosterone level of <1 ng/dL, the serum brain natriuretic peptide of 15 pg/mL, and serum uric acid of 2.8 mg/dL. The diagnosis of CSWS was suspected, fludrocortisone was tried, and hypovolemia and hyponatremia improved. Cryptococcal meningitis in HIV patients can present with CSWS, and the distinction between CSWS and SIADH is important because the treatment for CSWS is different than that of SIADH. Both share a similar clinical picture except that CSWS presents with constant hypovolemia despite volume replacement. Salt tablets, normal saline, or fludrocortisone can be used for treatment.

Ambulatory Blood Pressure Monitoring in Lean, Obese and Diabetic Children and Adolescents.

AIM: To determine if children and adolescents who have obesity (Ob) or type 2 diabetes (T2DM) of relatively short duration have impaired cardiovascular function compared with lean subjects using 24-hour ambulatory blood pressure as a surrogate measure of evaluation. METHODS: We enrolled 100 African-Caribbean subjects (45 males/55 females), mean ages 14.4-15.2 years (range 11.8-18.5 years) and Tanner stage 4.2-4.8. Mean BMI for the Ob (n = 40), T2DM (n = 39) and lean (n = 21) groups were 40.3, 34.2 and 20.8, respectively (p < 0.01, Ob and T2DM vs. lean). Mean hemoglobin A1c in lean and Ob was 5.4 and 5.5% compared to 8.8% in T2DM (p < 0.001, T2DM vs. lean and Ob). Ambulatory blood pressure was recorded every 20 min over 24 h using Spacelabs 70207. RESULTS: Mean 24-hour, daytime and nighttime systolic blood pressure was significantly higher in Ob and T2DM compared with lean subjects (mean 24-hour 117 and 120 vs. 109 mm Hg; daytime 121 and 123 vs. 113 mm Hg; and nighttime 109 and 115 vs. 101 mm Hg; p < 0.01 for all time periods). The nocturnal systolic dip in Ob and T2DM did not differ from that of lean, whereas nocturnal diastolic dip decreased significantly in Ob and T2DM compared to lean (11.5 and 10.4 vs. 20.6 mm Hg; p < 0.01). Mean pulse pressure was significantly increased in the Ob and T2DM groups compared to lean subjects (51 and 54 vs. 45 mm Hg; p < 0.01). CONCLUSION: Adolescent Ob and T2DM groups share adverse risk factors, which may be harbingers of adult cardiovascular events.

A Case of Gestational Thyrotoxicosis Associated with Wernicke's Encephalopathy.

OBJECTIVE: To present a case of gestational thyrotoxicosis and hyperemesis gravidarum associated with Wernicke's encephalopathy. METHODS: We present a detailed case report with the clinical, imaging, and laboratory findings of the patient and review the pertinent literature. RESULTS: A 36-year-old woman at 14 weeks of gestation was admitted to the hospital for management of severe hyperemesis gravidarum (HG). While hospitalized, she developed low-grade fever, tachycardia, hypotension, and altered mentation. Laboratory tests were diagnostic of hyperthyroidism. Physical examination revealed a confused, lethargic woman with a normal-size thyroid and pendular nystagmus in primary and lateral gaze. She was treated empirically for thyroid storm with methimazole and other measures. A brain magnetic resonance imaging (MRI) study done later showed hyperintense abnormal signals in bilateral thalamic regions, consistent with Wernicke's encephalopathy (WE). She was immediately started on intravenous thiamine and her mental status improved considerably within 3 to 4 days. Within 2 weeks, the patient's thyroid-function tests normalized and methimazole was discontinued. A repeat brain MRI 6 months later showed marked reduction of signal intensity in both thalamic regions. CONCLUSION: This case demonstrates that gestational thyrotoxicosis in a patient with HG can precipitate acute WE, which may mimic thyroid storm and thus delay appropriate management of this neurologic disorder. We conclude that prophylactic thiamine administration may be considered before caloric replacement in patients who present with HG and acute neurologic dysfunction.

Vascular compliance in lean, obese, and diabetic children and adolescents: a cross-sectional study in a minority population.

BACKGROUND: In adults, both obesity and type 2 diabetes mellitus (T2DM) are positively correlated with cardiovascular disease mortality and arterial stiffness. Several studies of adults have shown that both obesity and T2DM are independently associated with increased arterial stiffness. However, little is known about the relationship between arterial compliance and cardiovascular disease risk in children. We assessed whether large and small arterial compliance is impaired in obese and diabetic pubertal children. METHODS: One hundred children of African-Caribbean ethnicity, aged 14-16 years, including 21 lean children (between the 25th and 75th percentile), 40 obese children (>95th percentile), and 39 children with T2DM diagnosed by American Diabetes Association criteria were studied. Arterial compliance of the large (C1) and small (C2) vessels was measured using radial arterial diastolic pulse wave contour analysis. RESULTS: C1 did not differ significantly between lean, obese, and T2DM subjects. C2 was significantly greater in obese and T2DM subjects (10.9 ± 1 and 10.4 ± 0.7 ml/mm Hg × 100 ml, respectively) compared to lean subjects (7.8 ± 0.8 ml/mm Hg × 100 ml; p < 0.05). C2 was also significantly greater in T2DM subjects receiving antihypertensive drug therapy than in diabetic subjects not on antihypertensive treatment. CONCLUSION: Increased compliance in diabetic and obese children compared to lean subjects could be secondary to premature maturation of the vascular system; whether this early maturation can translate into a subsequent rise in the incidence of cardiovascular events related to diabetes and obesity can only be determined by long-term follow-up of these patients.

Serum HSP70: a novel biomarker for early detection of pancreatic cancer.

OBJECTIVES: Heat shock protein 70 (HSP70) is overexpressed in human pancreatic cancer cell lines. To determine if serum HSP70 levels are elevated in patients with pancreatic cancer and can function as a biomarker for early detection of pancreatic cancer. METHODS: Study subjects were divided into 3 groups: histologically proven pancreatic cancer (PC; n = 23), chronic pancreatitis (CP; n = 12), and matched normal control subjects (C; n = 10). Serum HSP70 levels were determined using a novel immunoelectrophoresis method developed and validated by the authors. Significance of difference between the groups was analyzed with analysis of variance (ANOVA). Receiver operating characteristic (ROC) curve analysis was performed to discriminate patients with pancreatic cancer from normal controls. RESULTS: The mean ± SE serum HSP70 levels in the PC, CP, and C groups were 1.68 ± 0.083 ng/mL, 0.40 ± 0.057 ng/mL, and 0.04 ng/mL, respectively. Serum HSP70 levels in the PC group were significantly higher compared with either the CP or C groups (P < 0.01). The sensitivity and specificity of elevated serum HSP70 in the PC group was 74% and 90%, respectively. CONCLUSIONS: Serum HSP70 levels are significantly increased in patients with pancreatic cancer and may be useful as an additional biomarker for the detection of pancreatic cancer.

Multifocal epitheloid hemangioendothelioma of liver after long-term oral contraceptive use--a case report and discussion of management difficulties encountered.

CASE REPORT: A 43-year-old woman presented with right upper abdominal pain, on and off for 3-4 years. One year prior to her presentation, a space-occupying lesion was found in the right lobe of the liver, which was suspected to be hemangioma, as the patient had history of combined oral contraceptive pill use for the last 15 years. On examination, she was thinly built and had pallor; abdominal examination revealed tender hepatomegaly 3 cm below the costal margin, smooth surface, sharp regular edge with left lobe enlargement, and no bruit. RESULTS: All routine biochemical and hematologic investigations were normal, except hemoglobin of 7.6 gm/dl. On triple-phase CT scan, there were hypodense ill-defined lobulated area in right lobe of liver; similar lesions were also seen in segments V and VII of liver along with a few sub-diaphragmatic and para-aortic nodes. Liver biopsy showed features suggestive of hemangioendothelioma, and immunohistochemistry showed CD 31 and CD 34 positivity but negative for estrogen receptors. Laparoscopy revealed presence of multiple deposits on left lobe of liver and ascites. DISCUSSION: Tumor was unresectable, and the patient was found to be a candidate for liver transplant. Chemoembolization was tried as a palliation awaiting transplant, but the procedure was unsuccessful due to the hypovascular nature of the tumor. The patient died within 4 months of diagnosis due to liver failure, awaiting liver transplant, as a suitable donor was not available. CONCLUSION: A clinical suspicion based on demographics, risk factors and imaging, familiarity with the pathologic findings, and utilization of advanced imaging techniques may allow early diagnosis of these tumors and hence their appropriate management.

Apoptotic mechanisms in fulminant hepatic failure: potential therapeutic target.

INTRODUCTION: Pathogenesis of fulminant hepatic failure (FHF) in nonacetaminophen etiology is not elucidated. We have investigated the significance of tumor necrosis factor (TNF) type-I receptor (TNF-R1) and Fas receptor (CD95, APO-1) in FHF. METHODS: Liver biopsy samples were obtained from 14 FHF patients. Liver tissue samples of 10 patients with acute viral hepatitis (AVH) and 10 cases who died, unrelated to liver disease served as tissue biopsy controls. Immunohistochemical methods were employed to analyze expression of TNF-R1 and Fas expression in hepatocytes. RESULTS: Immunohistochemical analysis revealed high expression (P<0.001) of Fas and TNF-R1 in FHF cases in relation to AVH cases. This expression was more in cytoplasm of apoptotic hepatocytes than viable swollen hepatocytes and this correlated with the extent of hepatocyte apoptosis. The mean apoptotic index was significantly (P<0.001) higher in FHF in relation to AVH. CONCLUSIONS: Enhanced expression of TNF-R1 and Fas receptors on the apoptotic hepatocytes suggest that both may be involved in the pathogenesis of FHF and seem to be potential therapeutic target.

Inflammatory pseudotumour of the liver: a diagnostic dilemma.

Inflammatory pseudotumour is a rare, focal, benign inflammatory lesion of the liver parenchyma. It is largely a self-limiting entity and has favorable prognosis; it is thus important to preoperatively distinguish this lesion from malignancy, which it closely imitates. Inflammatory pseudotumour may present variously. We present the case of a 54-year old gentleman who presented with a three-month history of low-grade intermittent fever. Ultrasonography and computed tomography revealed a mass in the left lobe of the liver and the erythrocyte sedimentation rate was raised with coincident hypergammaglobulinaemia. A diagnostic laparotomy with left lateral hepatectomy was performed and histopathological evaluation of the specimen along with special staining and tissue culture revealed an inflammatory pseudotumour. On the second day post-operative the fever subsided and following an uneventful five days the patient was discharged and remains well at one-year follow up with no recurrence or relapse.